Exploring the business case for quality how medical care can evolve to meet patient needs
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Exploring the Business Case for Quality - How Medical Care Can Evolve to Meet Patient Needs. Molly Joel Coye, MD, MPH Founder and CEO Health Technology Center. The need for transformation: IOM Report - “The chassis is broken”. You can’t get there from here:

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Exploring the business case for quality how medical care can evolve to meet patient needs

Exploring the Business Case for Quality - How Medical Care Can Evolve to Meet Patient Needs

Molly Joel Coye, MD, MPH

Founder and CEO

Health Technology Center

www.healthtechcenter.org


The need for transformation iom report the chassis is broken

The need for transformation:IOM Report - “The chassis is broken”

  • You can’t get there from here:

    “The American health care delivery system is in need of

    fundamental change. The current care systems cannot do the

    job. Trying harder will not work. Changing systems of care will.”

    Winston Churchill had it right:

    "The Americans will always do the right thing... after they've exhausted all the alternatives.”

www.healthtechcenter.org


Aligning environmental forces

Aligning environmental forces

Four Critical Forces:

  • Information Technology

  • Payment - Reimbursement incentives

  • Clinical knowledge

  • Professional Workforce

www.healthtechcenter.org


What didn t work

What didn’t work?

  • Medical education and continuing medical education

  • Practice structure: medical groups and Independent Practice Associations

  • CQI

  • Accountability: measures and reporting

  • Information systems and physician profiling

  • Physician compensation and financial incentives

  • And why?

    • US healthcare market organization

    • leadership and culture

    • technology capabilities and support

    • consumer interest and pressure

www.healthtechcenter.org


Cqi the intermountain health system story

CQI: The Intermountain Health System Story

Brent James: LDS Hospital, Salt Lake City, Utah

  • 60 CQI projects over 10 years that were successful:

    • improved quality outcomes and patient satisfaction

    • narrowed variation and almost always reduced costs

    • only 2 were ever disseminated beyond index institutions

  • Why? - Example of antibiotic use to control pneumonia in hospital

    • reduced adverse events associated with antibitotic errors by 30%.

    • reduced mortality of patients treated with antibiotics 27%.

    • reduced overall antibiotic use by 23%.

    • reduced antibiotic costs per treated patient by 58%.

      Chassin, Health Affairs 5/97

www.healthtechcenter.org


The iom report information technology improves quality

The IOM Report: Information technology improves quality

  • Safety Computerized physician order-entry reduced adverse drug events by 55% (Bates, 1998)

  • EffectivenessReminder systems and computer assisted diagnosis and management improves compliance with practice guidelines (Durieux, 2000; Evans, 1998)

  • Patient-CenteredInternet can provide access to clinical knowledge, online support groups,customized health education and disease management messages

www.healthtechcenter.org


The iom report information technology improves quality1

The IOM Report: Information technology improves quality

  • Timelinessmothers receiving computer-generated reminders had 25% higher on-time immunization rate for their infants (Alemi, 1996)

  • Efficiency9% of redundant lab tests at a hospital could be eliminated using a computerized system (Bates, 1998)

  • EquityInternet-based health communication can improve access and provide a broader array of options for interacting with clinicians

www.healthtechcenter.org


The iom report information technology strategies

The IOM Report: Information technology strategies

  • There must be a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education.

  • This commitment should lead to the elimination of most handwritten clinical data by 2010

www.healthtechcenter.org


Iom what will be required

IOM: What will be required ?

Inside healthcare organizations:

  • Re-organize operations around core clinical processes

    • E.g., Pregnancy and delivery, diabetes ...

    • Reflect patient AND provider experience

  • Align measurement - external reporting as a sub-set of operations data (SEC / FASB)

  • Integrate ‘pieces’ of care - the patient as hub, not the site of care

www.healthtechcenter.org


Iom what will be required1

IOM: What will be required ?

The external environment = purchasers, regulators

  • Align payment

    • budget, not FFS at organization level

    • option: reflect clinical processes

  • Align consumer information

  • Give consumers more discretion

    • fate of defined contribution???

  • Align payment

www.healthtechcenter.org


Iom what will be required2

IOM: What will be required ?

The common denominators are:

  • consumers and providers (and purchasers) get information that is meaningful for

    • selection of providers = BUSINESS CASE

    • improvement = knowledge

  • payment (price, volume) rewards improved performance for meaningful units of care

    • budgets for populations

    • payment to providers for care processes

    • actuarial versus performance risk

  • Leapfrog Initiative

    • volumes/cardiac procedures

    • Intensive Care staffing

    • CPOE

www.healthtechcenter.org


Iom quality forum action at the health system level

IOM + Quality Forum: Action at the health system level

Health Delivery System Steps

  • Link information systems to clinical processes and financial analyses

    • build registries

    • support clinical practice: acute and ambulatory care

    • adopt new technologies in concert

  • Focus on variation:

    • capacity to detect

    • capacity to assess

    • capacity to change

  • Focus on quality waste

  • Build the internal business case while waiting for the external environment to change

www.healthtechcenter.org


Churchill also said give us the tools and we will finish the job

Churchill also said, "Give us the tools and we will finish the job."

  • Now we have new tools - technologies - with which to make these changes

  • IOM Committee on Quality of Healthcare in America:

    technology is no longer an option - it is an imperative

  • Healthcare leaders feel the pressure to change (Leapfrog) -

    • pipeline of technologies overwhelming

    • strategy options not easily apparent

    • and traditional methods of technology adoption no longer work

  • So..which tools? Which technologies?

www.healthtechcenter.org


Which tools which technologies

Which tools, which technologies?

  • Information Technology

    • ICU in a gurney

  • Devices

    • Hepatic dialysis

    • Polymers

  • Pharmaceuticals

    • Inhaled insulin

  • Biotechnology

www.healthtechcenter.org


Technology as strategy

Technology as strategy

  • A tool is not a strategy

  • Strategies involve disruptive technologies

    • radical disruption of business models and customer experience

    • make care radically better and cheaper for the consumer

  • The puzzle of the open market in healthcare:

    • ‘orphan technologies’ - NAS/IOM study

    • emerging business case for quality

    • emerging business case for cost reduction

  • learn from the developing world -

    employ technology for intentional change

www.healthtechcenter.org


Strategies for intentional change in the us

Strategies for intentional changein the US

  • Current pace of innovation and adoption so slow that

    • National Academies’ Board on Science, Technology and Economic Policy and

    • IOM Board on HealthCare Services

    • convened special project to identify public policies needed to

      “stimulate the development, adoption, and diffusion of high-value medical innovation.” (June 2001)

www.healthtechcenter.org


Intentional disruptive change which tools for chronic disease

Intentional, disruptive change - which tools for chronic disease?

MD receives alert reports,

adjusts Rx, revises surveys or

initiates a visit.

Substantial savings in emergency

visits and hospitalizations.

Sam’s nurse reviews symptoms, provides assistance or notifies Sam’s MD.

Sam steps onto scale.

“Good Morning, Sam.”

Scale reports weight, sends over web, reports progress & gives tailored Yes/No survey. Takes ~20 seconds

www.healthtechcenter.org


But tools are not strategy

But tools are not strategy

  • Strategy speaks to how we will

    • select tools

    • finance them

    • learn to use them

    • and why

  • Sensible strategies in the face of overwhelming possiblities involve collaboration -

    • turn fragmentation into a virtue

    • health systems form a national network of laboratories \

    • need systematic harvesting and dissemination of learnings

www.healthtechcenter.org


Strategy i check each technology against the iom six aims for quality improvement

Strategy I: Check each technology against the IOM six aims for quality improvement

  • Safe

  • Effective

  • Patient-centered (who defines…)

    • Heart Scan

    • Fully half of all adults polled interested in genetic test for a very serious disease even if there was no known treatment or a way to prevent it.

    • Would spend $300-400 for testing if treatment was available

  • Timely

  • Efficient

  • Equitable

IT

cost

Clinical technologies

= the ringer

diffusion

www.healthtechcenter.org


Strategy ii check each technology against the three legged stool

Strategy II: Check each technology against the ‘three-legged stool’

  • Quality

    • orphan technologies

      • chronic disease monitoring and remote patient management

      • Intensive Care staffing - Visicu.com

  • Cost

    • Where quality improvement

      • narrows variation,

      • eliminates error and

      • decreases process time

  • Access

  • and the fourth leg: consumer demand

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Strategy iii check for drag

Strategy III:Check for drag

  • Barriers - and solutions - are cross-industry

  • The checklist:

    • Culture

    • Guild

    • Lack of Toyotas

    • Quality hazards of implementation

    • Contradictory reimbursement schemes

    • Capital - human and financial

    • Leadership

    • Uncertainty - (Churchill again)

      "True genius resides in the capacity for evaluation of uncertain,

      hazardous and conflicting information."

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Strategy iv build national leadership

Strategy IV: Build national leadership

  • Urgency stressed by the NAS - IOM project

  • Value underscored by research on the value of innovation

  • Industry-wide strategies:

    • Provider systems and health plans

      • Leadership

      • Standards

      • Toyotas

      • Professional commitment

      • Collaboration in learning networks

    • Developers

      • Strategies

      • Crash projects for development to solve industry problems

    • Government strategies –

      • Standards

      • Coverage, reimbursement, conditions of participation

      • Financing - new investment strategies

www.healthtechcenter.org


Strategy vi develop forecasting information for delivery system leaders

Strategy VI: Develop forecasting information for delivery system leaders

Strategic information, from a new non-profit -

The Health Technology Center

  • Nature of scientific advances

  • Clinical program impacts

  • Probable products and services

  • Potential impact on delivery systems: clinical programs, facilities, workforce and market strategy

  • Potential impact on insurers: cost, coverage and reimbursement

  • Staging: timeline, promoters and inhibitors, sentinel events, wild cards

  • Leading companies developing technology, potential partners

  • Strategic assessment: options, migration pathways

www.healthtechcenter.org


Healthtech reports 2001 2002

Completed Reports

Minimally Invasive Surgery

Drug Delivery Devices

Sensors for Monitoring

Organ Assistance and Substitution

Stem Cells

Genetic Testing

Imaging

Tissue and Fluid Bioengineering

PACS and CAD

Point of Care: Mobile Computing

Networking

Cancer Pharmaceuticals and Biologics

Now Underway:

Robotics

Remote Patient Management

Security Technologies

Cardiovascular Pharmaceuticals

Anti-infectives

HealthTech Reports 2001-2002

www.healthtechcenter.org


Clocking the strategy vision and tactics

Clocking the strategy - vision and tactics

The vision is: To achieve a threshold change in the quality of

healthcare within this decade; major change within 5 years.

The change model is mostly hydraulic:

  • increase the pressure to changeLeapfrog, HCFA, health plan negotiations

  • remove barriers reimbursement incentives, technology investment

  • build the ‘escape hatch’ practical options: migration paths to quality

  • definitely unpredictablewho would have thought the VA would lead?

  • potentially explosivephysician reaction, lawsuits, legislation

www.healthtechcenter.org


Strategy vii build migration pathways

strategic objectives

visionary goals

tactical choices

Strategy VII: Build migration pathways

Quality healthcare: from vision to reality in a decade

  • Operating visions will span

    • quality aims

    • clinical processes

    • infrastructure

    • leadership and organization

  • Multiple pathways for each vision

    • segment by relevant differentiation among shareholders

    • tactical choices understood in context

    • tactical choices supported by relevant VHA analyses

5 yrs

10 yrs

5 year migration pathway

www.healthtechcenter.org


A new architecture for healthcare axis 1 the iom six aims for quality

A new architecture for healthcare: Axis 1 = the IOM six aims for quality

5 yrs

10 yrs

Safe

hand-held

prescription

lookup; phamacy screening

CPOE

ambulatory

prescriptions

electronic entry

5 yrs

10 yrs

Effective

clinical processes

defined, patient

registries built

15 chronic

disease

programs

implemented

ambulatory/in-home

chronic disease monitoring

5 yrs

10 yrs

Patient-centered

Timely

Efficient

Equitable

www.healthtechcenter.org


A new architecture for healthcare axis 1 the iom six aims for quality1

A new architecture for healthcare: Axis 1 = the IOM six aims for quality

5 yrs

10 yrs

Safe

hand-held

prescription

lookup; phamacy screening

CPOE

ambulatory

prescriptions

electronic entry

5 yrs

10 yrs

Effective

clinical processes

defined, patient

registries built

15 chronic

disease

programs

implemented

ambulatory/in-home

chronic disease monitoring

5 yrs

10 yrs

Patient-centered

IT STRATEGY

- investments

- workforce

- leadership

Timely

Efficient

Equitable

www.healthtechcenter.org


A new architecture for healthcare axis 2 clinical processes

A new architecture for healthcare: Axis 2 = clinical processes

5 yrs

10 yrs

Pregnancy and Delivery

C/S rate, variation

genetic

testing

genetic therapy

5 yrs

10 yrs

Cardiac Care

cardiac registries

established

endovascular

surgery

certification

achieved

ambulatory and in-home

monitoring; angiogenics

5 yrs

10 yrs

Diabetes

X

Y

pancreatic transplants,

stem cell

IOM 15 priority chronic conditions

+

80-20 rule for your institutions, populations

www.healthtechcenter.org


Exploring the business case for quality how medical care can evolve to meet patient needs

199920002001200220032004200520062007200820092010

Two Sensor Applications: Technology Timeline

ChipRx’s Schematic of a Self-Regulating Responsive Therapeutic System

Sensatex’s Smart Shirt

Long-term implantable glucose monitor developed

Long-term implantable glucose monitor becomes community standard

Long-term implantable glucose monitor FDA approved

Smart clothes developed

Noninvasive continuous glucose monitor developed

Noninvasive continuous glucose monitor FDA approved

Noninvasive continuous glucose monitor becomes community standard

Smart clothes become “accepted therapeutic choice”

Smart clothes FDA approved

Cygnus’ GlucoWatch Biographer

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Exploring the business case for quality how medical care can evolve to meet patient needs

The Vision

Advance the use of new technologies

to make people healthier

Strategic Partners

Sutter HealthProvidence Health

Kaiser PermanenteCarolinas Health

Group Health of Puget SoundPeace Health

VHA Inc.California Public Hospitals

Ascension HealthInstitute for the Future

Premier, Inc.Wellpoint Health Networks

HCACareScience

Markle FoundationHRET

Mills-Peninsula Health SystemECRI

Sequoia Healthcare DistrictParkview Health

Milbank FoundationThe California Endowment

www.healthtechcenter.org


Just give us the tools

Just give us the tools…

The future is here.

It's just not widely distributed yet.

www.healthtechcenter.org


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